Comorbid non-alcohol substance misuse among people with schizophrenia: epidemiological study in central London

Investigating gender differences in quality of life and social support in patients with severe mental illnesses

BACKGROUND

Severe mental illnesses (SMIs), including schizophrenia and bipolar disorder affect patients significantly. Gender has been identified as a key factor influencing the experience of SMIs with notable disparities in prevalence, symptoms, and treatment outcomes. Additionally, the quality of life (QoL) and social support for patients with SMIs can vary based on gender.

AIMS

This study examined gender differences in QoL and social support of patients with SMIs.

METHOD

Participants include 170 outpatients with schizophrenia and bipolar disorder at Shafa Hospital (2021). QoL and social support were assessed using World Health Organization QoL (WHOQOL-BREF) questionnaire and Medical Outcomes Study Social Support Survey (MOS-SSS), respectively. Group differences were analyzed using t-test or Mann-Whitney U test, and two-way multivariate analyses of variance explored the effect of gender and disease type.

RESULTS

It was indicated that females with schizophrenia reported higher QoL than males, but the opposite was observed for bipolar disorder. Gender differences in social support were not significant among schizophrenia patients, nor between the two patient groups. However, women with bipolar disorder and multiple hospitalizations experienced lower social support and QoL compared to men. Additionally, more hospitalizations were associated with decreased QoL in both genders with schizophrenia.

CONCLUSIONS

Findings suggest the need for gender- specific interventions and support policies to enhance QoL and social support in patients with SMI.

[The CIMH track concept in the treatment of psychotic disorders]

The treatment of psychotic disorders and illnesses is a challenge for therapists and institutions due to the heterogeneity of the cause and course, refractory symptoms, lack of therapy adherence and high rates of relapse. These circumstances can be effectively counteracted by the flexibility of therapeutic approaches and settings. A useful but rarely used concept is the treatment of psychoses within the so-called track unit. A track unit is defined as a syndrome-oriented, decentralized, modular unit, adjusted to the patient's individual stage-specific needs across both inpatient and outpatient sectors. The track concept offers a fully integrated sector-spanning model of treatment at all stages of psychotic illnesses as well as a continuity of treatment. Another important goal is the early availability of timely treatment for as many psychotic patients as possible so that the symptoms can be alleviated as soon as possible and the quality of life can be sustainably improved or preserved. The track concept not only improves the current situation of treatment for acutely or chronically psychotic patients but also represents a necessary investment in the future. This treatment model aims to ensure that the good but complex and costly treatment options are available to patients even if inpatient treatment is not favored by the patient.

Cannabis use and outcome of recent onset psychosis

Purpose

To test the hypothesis that recent onset psychotic patients who use cannabis will have psychotic symptoms that are more severe and more persistent than those who do not use cannabis.

Subjects and methods

We carried out a 4-year follow-up study of a cohort of 119 patients with recent onset of psychosis. The patients were divided into four groups according to duration of cannabis use, taking index admission and follow-up as reference points.

Results

Those subjects who persisted in the use of cannabis had more positive (but not negative) symptoms and a more continuous illness at follow-up.

Limitations

The main limitations of the study were: the relatively small sample size, and that the excess of male subjects and the presence of cannabis induced psychosis could have a confusing impact on the interpretation of the results.

Conclusion

It is possible that psychotic patients who use cannabis are at a greater risk of a more continuous illness with more positive symptoms than those who do not.

Quality of life and its association with current substance use, medication non-adherence and clinical factors of people with schizophrenia in Southwest Ethiopia: a hospital-based cross-sectional study

Background

Schizophrenia was ranked as one of the top ten illnesses contributing to the global burden of disease. But little is known about the quality of life among people with schizophrenia, in particular in low-income countries. This study was aimed to examine the association of quality of life with current substance use, medication non-adherence and clinical factors of people with schizophrenia at Jimma University Medical Center, psychiatry clinic, Southwest Ethiopia.

Methods

Institution based cross-sectional study design was employed. Study participants were recruited using a systematic random sampling method and a sample fraction of two was used after the first person was identified by the lottery method. we used the World Health Organization Quality of Life Scale-Brief version (WHOQoL-BREF) and 4-item Morisky Medication Adherence Scale (MMAS-4) to assess the quality of life and medication non-adherence respectively. Data about current substance use was assessed by yes/no questions. Descriptive statistics, such as frequency, mean and standard deviations were computed to describe the characteristics of the study population. Data entry was done using EpiData version 3.1 then exported to SPSS statistics version 25 for analysis and analyzed using multiple linear regression. The assumption for linear regression analysis including the presence of a linear relationship between the outcome and predictor variable, the test of normality, collinearity statistics, auto-correlation and homoscedasticity were checked. Un-standardized Beta (β) coefficients with 95% confidence interval (CI) and P-value < 0.05 were computed to assess the level of association and statistical significance in the final multiple linear regression analysis.

Result

In this study 31.65% of participants were medication non-adherent and total mean scores of quality of life showed a lower level of satisfaction in social relationship domain (10.14 ± 3.12). Our study showed 152(43.3%), 248(70.7%) and 97(27.6%) of respondents had used tobacco, Khat and alcohol atleast once during the past 3 months respectively. Final adjusted multiple regression model showed medication non-adherence has significant negative association with physical domain (beta = − 4.42, p < 0.001), psychological (beta = − 4.49, p < 0.001), social relationships (beta = − 2.29, p < 0.001) and environmental domains (beta = − 4.95, p < 0.001). Treatment duration has significant negative association with psychological domain (beta = − 0.17, p < 0.04), social relationship (beta = − 0.14, p < 0.005), environmental domain (beta = − 0.24, p < 0.02) and overall quality of life (beta = − 0.67, p < 0.02). Having comorbid physical illness has significant negative association with physical domain (beta = − 2.74, p < 0.001), psychological (beta = − 2.13, p < 0.004), social relationships (beta = − 1.25, p < 0.007), environmental domain (beta = − 3.39, p < 0.001) and overall quality of life (beta = − 9.9, p < 0.001). Current tobacco use has significant negative association with physical domain (beta = − 1.16, p < 0.004), psychological (beta = − 1.23, p < 0.001), social relationships (beta = − 0.88, p < 0.001), environmental domains (beta = − 1.98, p < 0.001) and overall quality of life (beta = − 5.73, p < 0.001). Also, current chewing khat has significant negative association with physical domain (beta = − 1.15, p < 0.003), psychological (beta = − 1.58, p < 0.001), environmental domains (beta = − 2.63, p < 0.001) and overall quality of life (beta = − 6.22, p < 0.001).

Conclusion

The social relationship domain of quality of life has the lowest mean score. Medication non-adherence, treatment duration, having a comorbid physical illness, current tobacco use and current chewing khat were found to have a statistically significant association with the overall quality of life. Therefore, treatments aimed to improve social deficits, medication non-adherence, comorbid physical illness and decrease substance abuse is imperative.

Sources of Distress in First-Episode Psychosis: A Systematic Review and Qualitative Metasynthesis

In this study, we aim to increase our understanding of the self-reported sources of distress among people who have experienced first-episode psychosis. Following a systematic literature search, 33 relevant studies containing first-person accounts of first-episode psychosis were identified, which were synthesized using thematic analysis. Two interrelated superordinate themes were identified: intrapersonal distress and interpersonal distress. Participants reported multiple, diverse, and multifaceted sources of distress across both themes. These were substantially different from those routinely recognized and targeted in clinical practice. This review suggests that practitioners who maintain a stance of genuine curiosity about the potential sources of distress for this population will be perceived as more helpful. The findings also highlight the importance of being service user-led when planning and delivering mental health care. Additional clinical and research implications are discussed.

Prevalence of comorbid substance use in schizophrenia spectrum disorders in community and clinical settings, 1990-2017: Systematic review and meta-analysis

BACKGROUND

Comorbidity is highly prevalent between substance use disorders (SUDs) and schizophrenia. This systematic review and meta-analysis estimated prevalence rates of SUDs in epidemiological and treatment-seeking patients diagnosed with schizophrenia or first episode psychosis.

METHODS

A literature search of Medline, EMBASE, PsycINFO and CINAHL databases was conducted from 1990 to 2017 inclusive. Prevalence of co-morbid SUDs and schizophrenia were extracted and odds ratios (ORs) were calculated using random effects meta-analysis. Combining like studies was dictated how authors reported substance use.

RESULTS

There were 123 included articles with a total sample size of 165,811 subjects that yielded six epidemiological studies, 11 national or state case-registry studies, 20 large cohort studies and 86 clinical studies using in- or out-patient samples. The prevalence of any SUD was 41.7%, followed by illicit drugs (27.5%), cannabis (26.2%), alcohol (24.3%) and stimulant use (7.3%). Meta-analysis showed the pooled variance of any SUD in males was 48% which was significantly higher than that for females with schizophrenia (22.1%, OR 3.43, 95% CI 3.01, 3.92). Patients with SUD had an earlier age of onset of schizophrenia. Meta-regression showed prevalence increased over time for illicit drugs but not for other substances, including alcohol.

CONCLUSIONS

The meta-analysis revealed that SUDs in schizophrenia is highly prevalent and rates have not changed over time. This indicates SUD are difficult to treat in this patient population and there is an urgent need for more informative studies to help develop better prevention, detection and treatment of SUDs in persons with schizophrenia and co-morbid disorders.

Patterns of Substance Abuse in Offenders With Schizophrenia- Illness-Related or Criminal Life-Style?

Objective: The impact of substance abuse on violent behavior in patients suffering from schizophrenia is well-known. However, the association between the pattern of substance abuse and certain aspects of criminal behavior like the severity of offense, the previous history of violence and the age at onset of the criminal career is still unclear. Method: To assess the relationship between substance abuse, schizophrenia and violent behavior we examined healthy non-offenders; healthy offenders; non-offenders suffering from schizophrenia; and offenders suffering from schizophrenia, with respect to different patterns of substance abuse (none, alcohol only, illicit drugs only, and multiple substances). Results: Healthy offenders as well as offenders and non-offenders suffering from schizophrenia are characterized by increased rates of alcohol and illicit drug abuse. Especially multiple substance abuse appears to lower the threshold of aggression and illegal behavior. This effect is more pronounced in subjects suffering from schizophrenia. In both offender groups the abuse of psychoactive substances is associated with an earlier onset of the criminal career, but has no impact on the severity of the offenses. Conclusion: Our results point to the need for a differentiated view on the contribution of substance abuse to the criminality of subjects suffering from schizophrenia.

Opioid abuse and hospitalization rates in patients with schizophrenia

BACKGROUND

Substance abuse worsens the course of schizophrenia, but it is not known whether or not there are differences between specific substances concerning their association with the hospitalizations of patients with schizophrenia.

AIMS

The primary aims of this study were to examine the possible associations between amphetamine, cannabis, and opioid abuse, and the risk of hospitalizations among patients with schizophrenia.

METHODS

The study population consisted of 146 patients with ICD-defined schizophrenia from two different geographical sites in Finland, and it included both inpatients and outpatients. Data were collected retrospectively from the patients' medical files. Substance abuse was defined as either harmful use or dependence according to ICD-10.

RESULTS

The cumulative prevalence of substance abuse was 10.9% (16/146) for cannabis, 8.9% (13/146) for amphetamine, and 4.1% (6/146) for opioids. Among patients with schizophrenia and abuse of any substance, the number of hospitalizations was about 1.5-fold when compared to those without substance abuse. The incidence rate ratio for hospitalizations was 2.9 (95% CI 2.47-3.63) for opioids, 2.0 (1.71-2.41) for amphetamine, and 1.6 (1.33-1.84) for cannabis, when compared with no abuse of each substance. The risk of hospitalizations was significantly higher for opioids when compared with amphetamine (p < 0.001) or cannabis (p < 0.001).

CONCLUSIONS

Harmful use or dependence of opioids among patients with schizophrenia is associated with significantly higher risk of hospitalizations than either harmful use or dependence of amphetamine or cannabis.

Differences between patients with schizophrenia with and without co-occurring methamphetamine use disorders in a Taiwanese public psychiatric hospital

This study aimed to examine the factors related to and the outcomes of schizophrenic patients with co-occurring methamphetamine use disorders (MUDs). All schizophrenic patients discharged from a psychiatric hospital between January 1, 2006, and December 31, 2006, were monitored. This study compared the important demographic and clinical variables between patients with co-occurring MUDs and those without, and postdischarge measured time to rehospitalization during a 1-year period. Seven hundred fifty-six patients were included in this study. Of these patients, 88 (11.6%) reported the use of methamphetamine. Univariate analyses indicated that male sex, low educational level, discharge against medical advice, missed first appointment after discharge, co-occurring other illicit substance use disorder, age (younger), diazepam equivalents prescribed at discharge (higher), number of previous admissions within the past 5 years (higher), and length of hospital stay (longer) were predictive of patients with co-occurring MUDs. There were also significant differences in time to rehospitalization between these two groups during the follow-up periods. Many factors can be identified in schizophrenic patients with co-occurring MUDs. Furthermore, schizophrenic patients with co-occurring MUDs were more likely to be rehospitalized. Future studies in many different mental health systems are needed before these findings can be generalized.

Cannabis and schizophrenia

BACKGROUND

Schizophrenia is a mental illness causing disordered beliefs, ideas and sensations. Many people with schizophrenia smoke cannabis, and it is unclear why a large proportion do so and if the effects are harmful or beneficial. It is also unclear what the best method is to allow people with schizophrenia to alter their cannabis intake.

OBJECTIVES

To assess the effects of specific psychological treatments for cannabis reduction in people with schizophrenia.To assess the effects of antipsychotics for cannabis reduction in people with schizophrenia.To assess the effects of cannabinoids (cannabis related chemical compounds derived from cannabis or manufactured) for symptom reduction in people with schizophrenia.

SEARCH METHODS

We searched the Cochrane Schizophrenia Group Trials Register, 12 August 2013, which is based on regular searches of BIOSIS, CINAHL, EMBASE, MEDLINE, PUBMED and PsycINFO.We searched all references of articles selected for inclusion for further relevant trials. We contacted the first author of included studies for unpublished trials or data.

SELECTION CRITERIA

We included all randomised controlled trials involving cannabinoids and schizophrenia/schizophrenia-like illnesses, which assessed:1) treatments to reduce cannabis use in people with schizophrenia;2) the effects of cannabinoids on people with schizophrenia.

DATA COLLECTION AND ANALYSIS

We independently inspected citations, selected papers and then re-inspected the studies if there were discrepancies, and extracted data. For dichotomous data we calculated risk ratios (RR) and for continuous data, we calculated mean differences (MD), both with 95% confidence intervals (CI) on an intention-to-treat basis, based on a fixed-effect model. We excluded data if loss to follow-up was greater than 50%. We assessed risk of bias for included studies and used GRADE to rate the quality of the evidence.

MAIN RESULTS

We identified eight randomised trials, involving 530 participants, which met our selection criteria.For the cannabis reduction studies no one treatment showed superiority for reduction in cannabis use. Overall, data were poorly reported for many outcomes of interest. Our main outcomes of interest were medium-term data for cannabis use, global state, mental state, global functioning, adverse events, leaving the study early and satisfaction with treatment. 1. Reduction in cannabis use: adjunct psychological therapies (specifically about cannabis and psychosis) versus treatment as usualResults from one small study showed people receiving adjunct psychological therapies specifically about cannabis and psychosis were no more likely to reduce their intake than those receiving treatment as usual (n = 54, 1 RCT, MD -0.10, 95% CI -2.44 to 2.24, moderate quality evidence). Results for other main outcomes at medium term were also equivocal. No difference in mental state measured on the PANSS positive were observed between groups (n = 62, 1 RCT, MD -0.30 95% CI -2.55 to 1.95, moderate quality evidence). Nor for the outcome of general functioning measured using the World Health Organization Quality of Life BREF (n = 49, 1 RCT, MD 0.90 95% CI -1.15 to 2.95, moderate quality evidence). No data were reported for the other main outcomes of interest 2. Reduction in cannabis use: adjunct psychological therapy (specifically about cannabis and psychosis) versus adjunct non-specific psychoeducation One study compared specific psychological therapy aimed at cannabis reduction with general psychological therapy. At three-month follow-up, the use of cannabis in the previous four weeks was similar between treatment groups (n = 47, 1 RCT, RR 1.04 95% CI 0.62 to 1.74, moderate quality evidence). Again, at a medium-term follow-up, the average mental state scores from the Brief Pscychiatric Rating Scale-Expanded were similar between groups (n = 47, 1 RCT, MD 3.60 95% CI - 5.61 to 12.81, moderate quality evidence). No data were reported for the other main outcomes of interest: global state, general functioning, adverse events, leaving the study early and satisfaction with treatment. 3. Reduction in cannabis use: antipsychotic versus antipsychotic In a small trial comparing effectiveness of olanzapine versus risperidone for cannabis reduction, there was no difference between groups at medium-term follow-up (n = 16, 1 RCT, RR 1.80 95% CI 0.52 to 6.22, moderate quality evidence). The number of participants leaving the study early at medium term was also similar (n = 28, 1 RCT, RR 0.50 95% CI 0.19 to 1.29, moderate quality evidence). Mental state data were reported, however they were reported within the short term and no difference was observed. No data were reported for global state, general functioning, and satisfaction with treatment.With regards to adverse effects data, no study reported medium-term data. Short-term data were presented but overall, no real differences between treatment groups were observed for adverse effects. 4. Cannabinoid as treatment: cannabidiol versus amisulprideAgain, no data were reported for any of the main outcomes of interest at medium term. There were short-term data reported for mental state using the BPRS and PANSS, no overall differences in mental state were observed between treatment groups.

AUTHORS' CONCLUSIONS

Results are limited and inconclusive due to the small number and size of randomised controlled trials available and quality of data reporting within these trials. More research is needed to a) explore the effects of adjunct psychological therapy that is specifically about cannabis and psychosis as currently there is no evidence for any novel intervention being better than standard treatment,for those that use cannabis and have schizophrenia b) decide the most effective drug treatment in treating those that use cannabis and have schizophrenia, and c) assess the effectiveness of cannabidiol in treating schizophrenia. Currently evidence is insufficient to show cannabidiol has an antipsychotic effect.

Severe and enduring mental health problems within an established substance misuse treatment partnership

Aims and method The study reports findings of an investigation into the presence of severe and enduring mental health problems within the four statutory and non-statutory teams of an established substance misuse treatment partnership.

Results Of a total of 772 clients in the four teams surveyed, 69 (8.9%) were identified as having severe and enduring mental health problems and problem substance use in the past 12 months. Alcohol was the most prevalent substance used by this predominantly male group. Different rates were found across the four teams, with higher numbers in the non-statutory teams. The clients displayed significant levels of self-harm and suicide risk and were responsible for 131 acute service contacts over the past 12 months.

Clinical implications Clients with severe and enduring mental health problems engaged with substance misuse services display high levels of complex need. It is important to identify the best and most effective service response to this group.

Substance use disorders in hospitalized psychiatric patients: the experience of one psychiatric emergency service in Turin

In the present study we sought: 1) to estimate the frequency of substance use disorders (SUD), and 2) to investigate whether there is a mere association between diagnosis and SUD in a large cohort of patients with severe psychiatric disorders representative of the usual setting and modality of care of a psychiatric emergency service in a geographically well-defined catchment area in Italy, independent of sociodemographic features, anamnestic data and clinical status. The study was conducted between January 2007 and December 2008. The following rating scales were performed: the Clinical Global Impression-Severity (CGI-S), the Global Assessment of Functioning scale (GAF) and the Brief Psychiatric Rating Scale (BPRS). Factors found to be associated (p<0.05) with SUD[+] in the univariate analyses were subjected to multilevel logistic regression model with a backward stepwise procedure. Among 848 inpatients of our sample 29.1% had a SUD codiagnosis. Eleven factors accounted for 30.6% of the variability in SUD[+]: [a] a Personality Disorder diagnosis, [b] a Depressive Disorder diagnosis, [c] male gender, [d] previous outpatient contacts, [e] single marital status, [f] no previous psychiatric treatments, [g] younger age, [h] lower scores for BPRS Anxiety-depression and [i] BPRS Thought Disturbance, [l] higher scores for BPRS Activation and [m] BPRS Hostile-suspiciousness. The findings are important in identifying (1) the complexity of the clinical presentation of SUD in a inpatients sample, (2) the need for collaboration among health care workers, and (3) the need to develop and apply treatment programs that are targeted at particular risk groups.

Impact of substance use disorder on presentation and short-term course of schizophrenia

The aim of the present study was to compare a cohort of schizophrenia patients with substance use disorder (SUD) with a similar cohort of schizophrenia patients without SUD with regard to sociodemographic variables, clinical variables, psychopathology, anxiety symptoms, depressive symptoms, treatment outcome, and side effect profile of drugs. A total of 143 consecutive inpatients with ICD-10 DCR diagnosis of schizophrenia were included after obtaining informed consent. Patients were evaluated by a semistructured data sheet and Maudsley Addiction Profile. They were then rated by Positive and Negative Symptoms Scale, Calgary Depression Scale, Hamilton Anxiety Rating Scale, and Brief Psychiatric Rating Scale at presentation, three weeks, and six weeks. At three weeks and six weeks, they were also evaluated by UKU Side Effect Rating Scale. Substance abuse was detected in 63.6% schizophrenia patients. Nicotine was the commonest substance followed by cannabis and alcohol. Substance users had longer untreated illness and more depressive symptoms at presentation and six-week follow-up. Dual diagnosis patients had difficulty in abstraction at three and six weeks but not at presentation. Schizophrenia patients with SUD had more depressive symptoms. SUD appeared to mask abstraction difficulties at presentation. Schizophrenia patients with SUD should be carefully assessed for presence of depression.

Comorbid substance abuse in first-episode schizophrenia: effects on cognition and psychopathology in the EUFEST study

Studies and meta-analyses investigating the influence of substance use disorder (SUD) (substance abuse or dependence) on psychopathology and neurocognitive function in schizophrenia patients have revealed controversial results. Most studies did only have small samples and did not focus exclusively on first-episode schizophrenia patients.

METHOD

In a post-hoc analysis of the European First Episode Schizophrenia Trial (EUFEST) psychopathology and cognitive performances of patients with (FE-SUD, N=119, consisting of N=88 patients with persisting SUD at baseline and N=31 patients with previous SUD) and without SUD (FE-non-SUD, N=204) were compared at baseline and 6 months follow-up. Neurocognitive assessment included the Rey Auditory Verbal Learning Test (RAVLT); Trail Making Tests A and B (TMT), Purdue Pegboard and Digit-Symbol Coding.

RESULTS

In total 31.1% of patients reported SUD, and 22.2% of patients used cannabis. There were no significant differences between patients with and without SUD concerning PANSS scores, extrapyramidal motor symptoms or neurocognitive measures except better performance in psychomotor speed (TMT-A, p=0.033, Cohen's d=0.26) in patients with SUD at 6 months follow-up. Interestingly, SUD patients with ongoing substance use at follow-up showed elevated positive symptoms (PANSS positive score, p=0.008, Cohen's d=0.84) compared to those who abstained. PANSS scores at baseline were increased in patients with an onset of SUD before the age of 16 years. In addition we found a correlation between longer duration of cannabis use and higher cognitive performance as well as reduced symptom improvement and more extrapyramidal motor symptoms in patients with higher frequency of cannabis consumption.

CONCLUSIONS

FE-SUD and FE-non-SUD show similar psychopathology and neuropsychological performances at baseline and during the first 6 months of antipsychotic treatment.

Chronic cannabinoid exposure reduces phencyclidine-induced schizophrenia-like positive symptoms in adult rats

RATIONALE

Chronic cannabis use can induce psychotic states that resemble schizophrenia. Yet, schizophrenic patients often smoke cannabis as a form of self-medication to counter the aversive symptoms of schizophrenia. We recently demonstrated an ameliorating effect of cannabinoid self-administration (SA) on negative and cognitive schizophrenia-like symptoms induced experimentally by the non-competitive N-methyl-D-aspartate receptor antagonist phencyclidine (PCP). Whether cannabinoid SA alleviates or exacerbates schizophrenia-like positive symptoms is still unclear.

OBJECTIVES

This follow-up study aimed to evaluate the effect of self-administered cannabinoid on PCP-induced schizotypic positive symptoms in adult rats.

METHODS

Male rats were trained to self-administer either the cannabinoid CB1 receptor agonist WIN 55,212-2 (WIN; 12.5 μg/kg/infusion) or its vehicle (Veh) intravenously. The effects of acute and chronic intermittent intraperitoneal administration of PCP (2.5 mg/kg) on motor parameters were then tested in Veh-SA and WIN-SA.

RESULTS

Cannabinoid SA significantly attenuated the psychotomimetic effects of PCP exposure observed in control rats. Following acute PCP administration, WIN-SA animals displayed more frequent rearing and lower anxiety-like profile than Veh-SA rats. WIN-SA rats also exhibited lower behavioural sensitisation to chronic PCP treatment as demonstrated by reduced hyperlocomotion in response to an acute PCP challenge. In addition, parallel experiments performed in experimenter-administered rats that received WIN at comparable SA doses confirmed the ameliorating effects of cannabinoid exposure on PCP-induced schizotypic behaviours, indicating that motivational effects were not responsible for the ameliorative effects of cannabinoids.

CONCLUSIONS

Our results indicate that cannabis may exert protective effects on positive schizotypic symptoms in adult animals such as hypermotility and anxiety state.

The pharmacological management of violence in schizophrenia: a structured review

Although the increased risk of violent behavior in individuals with schizophrenia is now well-established, there is considerable uncertainty in pharmacological strategies to reduce this risk. In this review, we performed a systematic search of three electronic databases from January 2000 to March 2010 of treatment research on the management of violence in schizophrenia. We identified eight randomized controlled trials. The main findings included the association of nonadherence to antipsychotic medication to violent outcomes, a specific anti-aggressive effect of clozapine and short-term benefits of adjunctive β-blockers. There was little evidence on the efficacy of adjunctive mood stabilizers, depot medication or electroconvulsive therapy. Future research should use validated outcomes, longer follow-up periods and investigate patients with comorbid substance misuse.

Lateral ventricle differences between first-episode schizophrenia and first-episode psychotic bipolar disorder: A population-based morphometric MRI study

OBJECTIVES

The extent to which psychotic disorders fall into distinct diagnostic categories or can be regarded as lying on a single continuum is controversial. We compared lateral ventricle volumes between a large sample of patients with first-episode schizophrenia or bipolar disorder and a healthy control group from the same neighbourhood.

METHODS

Population-based MRI study with 88 first-episode psychosis (FEP) patients, grouped into those with schizophrenia/schizophreniform disorder (N=62), bipolar disorder (N=26) and 94 controls.

RESULTS

Right and left lateral ventricular and right temporal horn volumes were larger in FEP subjects than controls. Within the FEP sample, post-hoc tests revealed larger left lateral ventricles and larger right and left temporal horns in schizophrenia subjects relative to controls, while there was no difference between patients with bipolar disorder and controls. None of the findings was attributable to effects of antipsychotics.

CONCLUSIONS

This large-sample population-based MRI study showed that neuroanatomical abnormalities in subjects with schizophrenia relative to controls from the same neighbourhood are evident at the first episode of illness, but are not detectable in bipolar disorder patients. These data are consistent with a model of psychosis in which early brain insults of neurodevelopmental origin are more relevant to schizophrenia than to bipolar disorder.

How is substance use linked to psychosis? A study of the course and patterns of substance dependence in psychosis

Substance use in mentally ill patients is now a major problem that influences the course and outcome of psychosis. With prevalence ranging up to 60%, several theories were postulated to explain the link. It would be interesting to know if substances have different effects in persons with psychosis than in those without. This study aimed to explore patterns of symptomatology of dependence and comorbid psychiatric illness by comparing and contrasting it with a group suffering from pure substance dependence. Consecutively admitted patients who were matched for age, sex, and tobacco use were divided into 3 groups. These were substance dependence without any comorbid psychiatric disorder (SD; n = 32), schizophrenia with substance dependence (SC; n = 31), and bipolar disorder with substance dependence (BD; n = 31). Patients were administered the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and Mini International Neuropsychiatric Inventory (MINI) to evaluate the chronology of criterion of International Classification of Diseases (ICD)-10 dependence. Results showed that cannabis was the most common substance used by both the SC (100%) and BD (80%) groups. This was followed by alcohol as the most common substance used, with prevalence of 87% in SC and 77% in BD groups. There was a significant difference in the pattern of use of cannabis in patients with psychosis, who developed tolerance much faster (P = .018) and had longer durations of cannabis use (P = .001) than the SD group. The presence of "loss of control" over drug use criterion seems to be a specific marker predicting development of dependence and psychosis. Cannabis use is more strongly associated with development of psychosis than any other substance.

Evaluating integrated MI and CBT for people with psychosis and substance misuse: recruitment, retention and sample characteristics of the MIDAS trial

Major problems with existing RCTs evaluating psychosocial interventions for psychosis and substance misuse have been identified, in particular small sample sizes, high attrition rates, and short follow up periods. With a sample size of 327 and a follow up of 2 years, the MIDAS trial in the UK is to date the largest RCT for people with psychosis and substance use and is evaluating an integrated MI and CBT ("MiCBT") client therapy. Whilst the outcomes of the study are not yet available, data on recruitment and retention indicate that attrition rates in MIDAS are low and the majority of those allocated to treatment received a substantial number of therapy sessions. Sample characteristics are in line with those reported in epidemiological studies and are indicative of the challenges facing mental health services attempting to manage the client group: substance use is often longstanding, with frequent use at moderate or severe level and low motivation for change, and seen in the context of low levels of functioning and significant psychopathology. We conclude that this is a methodologically robust study that will have results generalisable to mental health services.

Substance abuse is associated with increased extrapyramidal symptoms in schizophrenia: a meta-analysis

BACKGROUND

Psychoactive substances (PAS) may interact with antipsychotics in the development of extrapyramidal symptoms (EPS) in schizophrenia. PAS exert acute and chronic impacts on the basal ganglia. Clinical data have been gathered about the effects of PAS on EPS in schizophrenia, producing inconsistent results. This meta-analysis sought to determine whether PAS enhance EPS in schizophrenia patients.

METHODS

A search of the literature using computerized engines was undertaken. Studies were retained in the analysis if: (i) they included schizophrenia patients with and without substance abuse; and (ii) they comprised a measure of EPS using valid instruments.

RESULTS

Sixteen studies available were identified, involving 3479 patients. The composite analysis revealed a small and positive effect size (g=0.260), suggesting increased EPS in substance-abusing patients. Cocaine was associated with the largest effect size estimate (g=0.613). Dual diagnosis patients were more frequently males than single diagnosis patients. Thus, we performed a sub-analysis of studies with no confounders (e.g. age, sex and/or symptoms). The pooling of these 10 studies produced a moderate and positive effect size (g=0.401).

DISCUSSION

Our results show that PAS negatively impact on EPS in schizophrenia, especially when potential confounding factors are controlled. Cocaine emerged as the PAS with the most deleterious effects on EPS in schizophrenia. Our results have implications for the prevention of EPS in schizophrenia and for the design of future studies on the topic.

Comorbidity of Axis I and II mental disorders with schizophrenia and psychotic disorders: findings from the National Epidemiologic Survey on Alcohol and Related Conditions

OBJECTIVE

To examine the comorbidity of Axis I and II disorders within a community-based sample of adults with schizophrenia.

METHODS

The study was conducted using data from the National Epidemiologic Survey of Alcohol and Related Conditions. A diagnosis of schizophrenia was based on respondents' self-report that they had been diagnosed by a health professional with schizophrenia or a psychotic illness or episode (SPIE). Axis I disorders and Axis II personality disorders (PDs) were assessed using the Alcohol Use Disorders and Associated Disabilities Interview Schedule. Mental and physical quality of life were assessed using the Medical Outcomes Study Short Form 12 questionnaire.

RESULTS

The prevalence of SPIE was 0.9%. We used multiple logistic regression to examine the association between the presence and absence of SPIE in Axis I and II mental disorders. Each of the Axis I and II mental disorders examined were significantly associated with a diagnosis of SPIE after controlling for age, sex, education, marital status, and household income.

CONCLUSIONS

Clinicians should be aware of the patterns and extent of psychiatric comorbidities that may exist in schizophrenia. Possible mechanisms of these associations are discussed.

The role of cannabis in cognitive functioning of patients with schizophrenia

RATIONALE

Cognitive deficits are commonly found both in patients with schizophrenia (SCH) and in people with cannabis use disorders (CUD). Surprisingly, some small recent studies reported better cognitive performance in SCH patients with comorbid cannabis use disorders (SCH + CUD) compared to other SCH patients.

OBJECTIVES

The aim of the present study was to investigate the residual impact of CUD and specific patterns of consumption on cognition in a larger sample of SCH + CUD patients.

METHODS

We administered a cognitive test battery to 34 SCH and 35 currently abstinent SCH + CUD patients. We explored the association between patterns of cannabis consumption and cognitive performance. Potential confounds with influence on cognitive ability were assessed and controlled for.

RESULTS

SCH + CUD patients had poorer academic achievements and lower vocabulary scores, but they performed better in tests of verbal and working memory, visuomotor speed and executive function (p < .05). More frequent cannabis use was associated with better performance in attention and working memory tasks.

CONCLUSIONS

Although our findings might be interpreted as beneficial effect of cannabis use on cognition in patients with schizophrenia, we favorise an alternative interpretation: in our view, the better cognitive functioning of SCH + CUD patients may rather reflect a relatively lower vulnerability to psychosis compared to the SCH group. Lower vulnerability may correspond to a higher level of functioning such as cognitive ability. This conclusion is consistent with the view of cannabis playing a critical role in the manifestation of psychosis in at least some of the SCH + CUD patients.

Variations in rates of comorbid substance use in psychosis between mental health settings and geographical areas in the UK. A systematic review

BACKGROUND

Comorbid substance misuse in psychosis is associated with significant clinical, social and legal problems. An epidemiologically informed approach to planning service delivery requires an understanding of which clinical populations are at particularly high risk for such 'dual diagnosis'. Evidence has now been accumulating in the UK since the early 1990s, and allows a relatively comprehensive comparison of rates between service settings, geographical areas and social contexts in terms of ethnic background.

METHODS

A literature search was carried out with the aim of investigating: (a) comorbid alcohol and drug misuse rates in people with established psychosis in different mental health and addiction settings in the UK, (b) variations in such rates between different population groups.

RESULTS

There are wide variations in reported drug and alcohol misuse rates in psychosis. Most recent UK studies report rates between 20 and 37% in mental health settings, while figures in addiction settings are less clear (6-15%). Rates are generally not as high as in US studies, but appear to be especially high in inpatient and crisis team settings (38-50%) and forensic settings. In terms of geography, rates appear highest in inner city areas. Some ethnic groups are over-represented among clinical populations of people with dual diagnosis.

CONCLUSIONS

Rates of substance misuse in psychosis are likely to be influenced by service setting, population composition and geography. Acute and forensic settings are especially appropriate for the development of targeted interventions.

Comorbid substance abuse and brain morphology in recent-onset psychosis

The aim of the presented study was to compare schizophrenia and schizoaffective patients early in the course of the disease with and without comorbid substance abuse disorder (SUD vs. NSUD) with regard to brain morphology. In a prospective design 41 patients (20 SUD vs. 21 NSUD) diagnosed as recent-onset schizophrenia or schizoaffective disorder consecutively admitted to hospital received standardized psychopathological evaluation (BPRS, SANS, MADRS, CGI, GAF) and MRI scanning with volumetric measurement of superior temporal gyrus (STG), amygdala-hippocampal complex, and cingulum. Patients with SUD (primarily cannabis) were significantly younger, predominantly male and had a lower socioeconomic status. Despite less attentional impairment (SANS subscore) and elevated anxiety/depression (BPRS subscore) in patients with SUD compared to NSUD, no other psychopathological differences could be detected. There were no differences in the assessed temporolimbic brain morphology between the two subgroups. In conclusion, in this study substance abuse in recent-onset psychosis had no effect on brain morphology and the earlier onset of psychosis in patients with comorbid SUD could not be explained by supposed accentuated brain abnormalities in temporolimbic regions.

Substance use disorders among psychotic patients admitted to inpatient psychiatric care

Previous epidemiological and clinical studies have shown high rates of substance use disorders in patients with psychotic disorders. There are few studies from the Scandinavian countries. The aim of this study was to investigate the rate of substance use disorders in a group of Norwegian psychotic inpatients from a specific catchment area. Sixty patients, aged 18-40 years, were interviewed through standardized methods: the Addiction Severity Index (EuropASI) and the Structured Clinical Interview for DSM-IV axis I disorders (SCID-I). Urine toxicology screens confirmed patients' self-report of recent substance use. The lifetime rate of substance use disorders was 70% when all psychotic disorders were included and 62.5% when substance-induced psychotic disorders were excluded. Fifty percent of all the patients studied had current substance use disorders. The majority of substance use disorders were dependence disorders. Alcohol, amphetamine and cannabis were the dominant substances. The level of comorbidity found in this study is comparable with that found in American studies, despite lower prevalence of substance use in the Norwegian population. The high rate of substance use disorders in psychotic inpatients has implications for the treatment and the organization of psychiatric care for these patients.

Treatment approaches for dual diagnosis clients in England

INTRODUCTION

Dual diagnosis (DD, co-occurrence of substance use and mental health problems) prevalence data in England are limited to specific regions and reported rates vary widely. Reliable information on actual service provision for dual diagnosis clients has not been collated. Thus a national survey was carried out to estimate dual diagnosis prevalence in treatment populations and describe the service provision available for this client population in drug/alcohol (DAS) and mental health services (MHS).

DESIGN

A questionnaire was sent to managers of 706 DAS and 2374 MHS. Overall, 249 (39%) DAS and 493 (23%) MHS participated in the survey.

RESULTS

In both DAS and MHS, around 32% of clients were estimated to have dual diagnosis problems. However, fewer than 50% of services reported assessing clients for both problem areas. Regarding specific treatment approaches, most services (DAS: 88%, MHS: 87%) indicated working jointly with other agencies. Significantly fewer services used joint protocols (DAS: 55%, MHS: 48%) or shared care arrangements, including access to external drug/alcohol or mental health teams (DAS: 47%, MHS: 54%). Only 25% of DAS and 17% of MHS employed dual diagnosis specialists.

CONCLUSIONS

Dual diagnosis clients constitute a substantial proportion of clients in both DAS and MHS in England. Despite recent policy initiatives, joint working approaches tend to remain unstructured.

Sex difference in age of onset of schizophrenia: findings from a community-based study in India

This study examined the sex difference in age of onset of schizophrenia in a community sample. Community-level health workers identified patients with symptoms of schizophrenia living in the community in a defined geographical area in South India. Two hundred and nine of them were diagnosed as hav-ing schizophrenia according to ICD-10 criteria by a team of psychiatrists. The age of onset of schizophrenia was assessed using the Interview for Retro-spective Assessment of Onset of Schizophrenia (IRAOS). The mean age of onset of schizophrenia did not significantly differ between males (29.2+/-8.8 years) and females (30.8+/-11.4 years) (t = 1.12; p = 0.27). Among those with an age of onset </=33 years, females had a significantly earlier onset; among those with an age of onset >33 years, females had a significantly later onset. The results from this community-based study confirm the previous findings in hospital-based patients in Asia. There is a need to revise the description of schizophrenia in the classificatory systems, keeping in view the regional varia-tions in the age of onset of the disorder.

Drug and alcohol misuse in first episode psychosis: An observational study

BACKGROUND

There have been very few observational studies of drug and alcohol misuse in first-episode psychosis in the UK.

METHOD

Using an observational database of first episode psychosis in Northumberland, a county in Northern England, information on patients aged 16 to 36 years were collected at presentation and annual follow-up between October 1998 and October 2005. Patterns of drug and alcohol misuse were compared using hospitalization as an outcome measure, and violence rates were examined retrospectively.

RESULTS

Drug misuse without alcohol misuse was associated with a highly significant increase in hospital days. An alcohol problem, either with or without coexisting drug misuse, was not predictive of increased hospital days. Drug and alcohol misuse together was associated with violence.

CONCLUSIONS

This paper lends some support to those Early Intervention in Psychosis (EIP) teams currently advising patients that drug misuse may have a greater impact than alcohol use on the outcome of first-episode psychosis.

Outcomes of public concern in schizophrenia

BACKGROUND

Schizophrenia is known to be associated with a range of adverse outcomes, which have an impact atthe societal level and are therefore of public concern.

AIMS

To examine the epidemiology and methods for measuring six adverse outcomes in schizophrenia: violence, victimisation, suicide/self-harm, substance use, homelessness and unemployment.

METHOD

A review ofthe literature was carried out for each adverse outcome, with attention to critical appraisal of existing measurement tools.

RESULTS

Schizophrenia is associated strongly with all six outcomes, although research has mainly focused on violence. Each outcome acts as a risk factor for at least some of the other outcomes. There are few standardised or validated measures for these 'hard' outcomes. Each measure has inherent biases but a growing trend is for these to be minimised by using multiple measures.

CONCLUSIONS

A single instrument which systematically measures multiple societal outcomes of schizophrenia would be extremely useful for both clinical and research purposes.

Naturalistic follow-up of co-morbid substance use in schizophrenia: the West London first-episode study

BACKGROUND

The impact of co-morbid substance use in first-episode schizophrenia has not been fully explored.

METHOD

This naturalistic follow-up of a cohort of 152 people with first-episode schizophrenia examined substance use and clinical outcome in terms of symptoms and social and neuropsychological function.

RESULTS

Data were collected on 85 (56%) of the patient cohort after a median period of 14 months. Over the follow-up period, the proportion of smokers rose from 60% at baseline to 64%. While 30% reported lifetime problem drinking of alcohol at baseline, only 15% had problem drinking at follow-up. Furthermore, while at baseline 63% reported lifetime cannabis use and 32% were currently using the drug, by the follow-up assessment the latter figure had fallen to 18.5%. At follow-up, persistent substance users had significantly more severe positive and depressive symptoms and greater overall severity of illness. A report of no lifetime substance use at baseline was associated with greater improvement in spatial working memory (SWM) at follow-up.

CONCLUSIONS

Past substance use may impede recovery of SWM performance in people with schizophrenia in the year or so following first presentation to psychiatric services. The prevalence of substance use other than tobacco tends to diminish over this period, in the absence of specific interventions. Persistent substance use in first-episode schizophrenia is associated with more severe positive and depressive symptoms but not negative symptoms, and should be a target for specific treatment intervention.

The neuropsychology of cannabis and other substance use in schizophrenia: review of the literature and critical evaluation of methodological issues

Research on the neuropsychology of substance use in schizophrenia has been steadily growing over the past decade. However, significant gaps remain in the knowledge of individual substances and their relationship to cognition in the schizophrenia spectrum disorders. Approximately 65 studies to date have directly examined this relationship. Of these, approximately 20 have focused on nicotine, 15 on alcohol, 10 on cocaine, three on stimulants/hallucinogens, one on benzodiazepines, 10 on polydrug abuse, and seven on cannabis. Research on cannabis is especially lacking, given that worldwide it is the most commonly used illicit drug in schizophrenia, is used at higher rates in schizophrenia than in the general population, and makes its own unique contribution to the onset and prognosis of schizophrenia. In the present paper an overview of the neuropsychology literature on substance use in schizophrenia is presented, with special emphasis on cannabis. This incorporates a discussion of the methodological limitations inherent in these studies, and range of potential confounding variables that were not considered or controlled, providing directions for future research into the cognitive correlates of cannabis and other substance use in schizophrenia.

Co-morbidity and cannabis use in a mental health trust in South East England

AIM

The prevalence of co-morbidity (severe mental illness and substance) may be less in rural and semi-rural areas than inner cities. The aims were therefore to measure the prevalence of co-morbidity among patients of attending a mental health service in a semi-rural area South East England.

DESIGN AND PARTICIPANTS

Cross-sectional prevalence survey of 1,808 patients with detailed assessments from a representative sample of 373 patients identified as having a combination of severe mental illness and substance misuse. Interviews with key workers were performed using validated methods from the COSMIC study.

RESULTS

The response rates equalled or exceeded 90% for the various parts of the study. One-tenth of patients attending the Community Mental Health Teams (CMHTs) reported problematic use of illicit drugs and 17% reported alcohol problems in the past year. 22% of Community Drug and Alcohol Service (CDAS) clients reported a severe mental illness and 46% reported some other form of psychiatric disorder. Of patients with a combined diagnosis of mental illness and substance misuse, cannabis use was 4-fold more common amongst patients attending the CMHT than CDAS (33% vs. 8%) while use of amphetamine was five-fold higher in the CMHT group (10% vs. 2%). Patients with concurrent psychiatric and substance misuse problems represent a similar proportion of the aggregate caseload of both treatment services with observed prevalence amongst the CDAS and CMHT patients with a diagnosis for anxiety disorder (18% vs. 26%), minor depression (42% vs. 32%), personality disorders (32% vs. 36%), histories of self-harm (52% vs. 46%) and violence (33% vs. 30%) respectively.

CONCLUSIONS

Co-morbidity is common in clients amongst CMHT and CDAS clients although use of cannabis was significantly more common in CMHT clients than in CDAS clients.

Cannabinoids influence lipid-arachidonic acid pathways in schizophrenia

Increasing evidence suggests modulating effects of cannabinoids on time of onset, severity, and outcome of schizophrenia. Efforts to discover the underlying pathomechanism have led to the assumption of gene x environment interactions, including premorbid genetical vulnerability and worsening effects of continuing cannabis use. The objective of this cross-sectional study is to investigate the relationship between delta-9-tetrahydrocannabinol intake and niacin sensitivity in schizophrenia patients and healthy controls. Intensity of niacin skin flushing, indicating disturbed prostaglandin-mediated processes, was used as peripheral marker of lipid-arachidonic acid pathways and investigated in cannabis-consuming and nonconsuming schizophrenia patients and in healthy controls. Methylnicotinate was applied in three concentrations onto the forearm skin. Flush response was assessed in 3-min intervals over 15 min using optical reflection spectroscopy. In controls, skin flushing was significantly decreased in cannabis-consuming as compared to nonconsuming individuals. When comparing the nonconsuming subgroups, patients showed significantly decreased flush response. The populations as a whole (patients and controls) showed an inverse association between skin flushing and sum scores of Symptom Check List 90-R. Results demonstrate an impact of long-term cannabis use on lipid-arachidonic acid pathways. Considering pre-existing vulnerability of lipid metabolism in schizophrenia, observed effects of cannabis use support the notion of a gene x environment interaction.

Comorbid substance abuse and neurocognitive function in recent-onset schizophrenia

Despite the high prevalence of comorbid substance use disorder (SUD) up to 65% in schizophrenia there is still few knowledge about the influence of substance abuse on neurocognitive function. In a prospective design we recruited 68 patients (aged 18-40 years) diagnosed as recent-onset schizophrenia or schizoaffective disorder consecutively admitted to hospital. The patients received standardized psychopathological evaluation of schizophrenic symptoms [Brief Psychiatric Rating Scale (BPRS), Scale for the Assessment of Negative Symptoms (SANS)], depressive symptoms [Montgomery Asberg Depression Rating Scale, (MADRS)] and global ratings [Clinical Global Impressions Scale (CGI), Global Assessment of Functioning Scale (GAF)]. Out of this sample 44 subjects underwent after stabilization (4-6 weeks after admission) neuropsychological investigation focusing on early information processing (Trail-Making-Test A, Digit Span), visuo-spatial ability (Corsi Block Tapping), verbal fluency (Verbal Fluency Test, semantic and letter category), and executive functioning and cognitive flexibility [Trail-Making-Test B, Wisconsin Card Sorting Test (WCST)]. About 36% of patients reported drug abuse [European Addiction Severity Index (EuropASI)] with a high prevalence for cannabis. Compared with nonabusers the sample of substance abusers was younger, predominantly male and had lower socioeconomic status. Attentional impairment according to the SANS subscale was less in abusers than in nonabusers on admission, no other psychopathological differences could be detected. Schizophrenic patients without substance abuse demonstrated significantly better performance only in a few neurocognitive tasks (Verbal Fluency, letter category and at trend level Digit Span, backwards), while there tended to be an advantage for substance abusers in executive functioning (WCST, not significant). These results are consistent with other studies of first-episode patients. The lack of higher cognitive disturbance in young schizophrenic patients with comorbid substance abuse may encourage clinicians to develop integrated treatment programmes using cognitive strategies of drug therapy.

The vulnerability to alcohol and substance abuse in individuals diagnosed with schizophrenia

Individuals with schizophrenia are at increased risk for developing substance abuse disorders. Here, we consider factors that might elevate their risk for substance abuse. The tendency among schizophrenic individuals to overvalue drug-like rewards and to devalue the potential negative consequences of substance abuse may be a contributing factor to their substance abuse risk. This bias, which may partly reflect the convergence of glutamatergic and dopaminergic input to the limbic striatum, also may contribute to disadvantageous decision-making and other impulsive behavior. This propensity to seek drug-like rewards is augmented by alterations in nicotinic cholinergic, GABAergic, glutamatergic, and cannabinnoid receptor function associated with schizophrenia that increase the abuse liability of low doses of nicotine, ethanol, and perhaps cannabis, and augment the dysphoric effects of higher doses of ethanol and cannabis. The distortions in reward processing and altered response to substances of abuse also increase the likelihood that individuals with schizophrenia will self-medicate their subjective distress with abused substances. The focus on distinctions between motivation and reward with respect to substance abuse risk by schizophrenic patients suggests a need for a reconsideration of the construct of "negative symptoms" for this dually-diagnosed patient group.

Reasons for increased substance use in psychosis

Around half of all patients with schizophrenia are thought to abuse drugs or alcohol and there is good evidence to suggest that they have poorer outcomes than their non substance using counterparts. However, despite more than twenty years of research there is still no consensus on the aetiology of increased rates of substance use in people with psychosis. There is a clear need to understand the reasons for such high rates of substance use if treatments designed to help patients abstain from substance use are to be successful. This paper provides an update of the literature examining the reasons for substance use by people with psychosis, and includes a comprehensive review of the self report literature. The main theories as to why people with psychosis use substances are presented. There is evidence to suggest that cannabis may have a causal role in the development of psychopathology but not for other substances. The self report literature provides support for an 'alleviation of dysphoria' model of substance use but there is little empirical support for the self medication hypothesis, or for common factor models and bidirectional models of comorbidity. It is likely that there are multiple risk factors involved in substance use in psychosis and more work to develop and test multiple risk factor models is required.

Working across boundaries: clinical outcomes for an integrated mental health service for people with intellectual disabilities

BACKGROUND

The Mental Health Service for People with Learning Disabilities (MHSPLD) is a service development in keeping with UK government policy that promotes cross agency working and access to mainstream mental health services for people with intellectual disabilities. We aimed to show whether the service model brought about improvements in people's mental state and level of functioning.

METHODS

Community and inpatient groups were compared across three time points using a range of clinical outcome measures that assessed psychiatric symptoms, risk, needs and level of functioning.

RESULTS

Inpatients and community groups had similar mental health problems, but inpatients had higher unmet needs and lower functioning, and were at greater risk. There were significant improvements across the range of outcome measures in both groups.

CONCLUSIONS

Working with mainstream mental health services and across health and social service boundaries delivers effective mental health care for people with intellectual disabilities.

Prevalence of substance use in a Swiss psychiatric hospital: interview reports and urine screening

BACKGROUND

Co-morbid substance misuse is common in psychiatric disorders, has potentially severe adverse consequences and may be frequently undetected.

AIMS

To measure the prevalence of substance use among patients admitted to a Swiss psychiatric hospital and to examine the potential utility of routine urine drug screening in this setting.

METHOD

266 inpatients were included. 238 patients completed the interview and 240 underwent a urine drug screening.

RESULTS

Lifetime prevalence of substance use among psychiatric patients was very high for alcohol (98%; 95% CI: 96-100), benzodiazepines (86%; 95% CI: 82-91) and cannabis (53%; 95% CI: 47-60), but also for "hard drugs" like cocaine (25% ; 95% CI: 19-30) or opiates (20%; 95% CI: 15-25). Regular current use of alcohol (32%; 95% CI: 26-38) or cannabis (17%; 95% CI: 12-22) was the most frequent. Substance use was associated with male sex, younger age, unmarried status and nicotine smoking. Urine screening confirms reports from patients on recent use, and remained positive for cannabis during hospitalisation, but not for cocaine nor for opiates.

CONCLUSION

Substance use is frequent among psychiatric patients. Systematic interviewing of patients about their substance use remains essential, and is usually confirmed by urine screening. Urine screening can be useful to provide specific answers about recent use.

Comorbid substance use and age at onset of schizophrenia

BACKGROUND

Substance use may be a risk factor for the onset of schizophrenia.

AIMS

To examine the association between substance use and age at onset in substance use and age at onset in a UK, inner-city sample of people with recent-onset schizophrenia.

METHOD

The study sample consisted of 152 people recruited to the West London First-Episode Schizophrenia Study. Self-reported data on drug and alcohol use, as well as information on age at onset of psychosis, were collected. Mental state, cognition (IQ, memory and executive function) and social function were also assessed.

RESULTS

In total, 60% of the participants were smokers, 27% reported a history of problems with alcohol use, 35% reported current substance use (not including alcohol), and 68% reported lifetime substance use (cannabis and psychostimulants were most commonly used). Cannabis use and gender had independent effects on age at onset of psychosis, after adjusting for alcohol misuse and use of other drugs.

CONCLUSIONS

The strong association between self-reported cannabis use and earlier onset of psychosis provides further evidence that schizophrenia may be precipitated by cannabis use and/or that the early onset of symptoms is a risk factor for cannabis use.

World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia, Part 1: acute treatment of schizophrenia

These guide lines for the biological treatment of schizophrenia were developed by an international Task Force of the World Federation of Societies of Biological Psychiatry (WFSBO). The goal during the development of these guidelines was to review systematically all available evidence pertaining to the treatment of schizophrenia, and to reach a consensus on a series of practice recommendations that are clinically and scientifically meaningful based on the available evidence. These guidelines are intended for use by all physicians seeing and treating people with schizophrenia. The data used for developing these guidelines have been extracted primarily from various national treatment guidelines and panels for schizophrenia, as well as from meta-analyses, reviews and randomised clinical trials on the efficacy of pharmacological and other biological treatment interventions identified by a search of the MEDLINE database and Cochrane Library. The identified literature was evaluated with respect to the strength of evidence for its efficacy and then categorised into four levels of evidence (A-D). This first part of the guidelines covers disease definition, classification, epidemiology and course of schizophrenia, as well as the management of the acute phase treatment. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication, other pharmacological treatment options, electroconvulsive therapy, adjunctive and novel therapeutic strategies) of adults suffering from schizophrenia.

Adolescence, schizophrenia and drug abuse: a window of vulnerability

OBJECTIVE

To discuss the neurobiological and psychosocial developmental factors in adolescence contributing to simultaneous onset and co-occurrence of psychosis and substance use disorders.

METHOD

A review of the literature.

RESULTS

Adolescence is a period with specific psychosocial challenges and specific changes in the brain that increase the probability of the onset of both psychosis and substance abuse, in predisposed people. In vulnerable adolescents it is proposed that an excessive pruning of dopaminergic neurones leads to mesocortical hypofrontality causing anhedonia and dysphoria. At the same time, anhedonia and dysphoria are important risk factors for the development of substance abuse. In turn, hypofrontality leads to a reduction in mesocortical feedback inhibition of the mesolimbic system resulting in aberrant salience and positive symptoms. Finally, the development of aberrant salience plays a role in both psychoses and craving.

CONCLUSION

Attention should be paid to the interaction of drug abuse and schizophrenia and an integrated treatment is needed. Dysphoria and anhedonia in schizophrenic adolescents are important factors in treatment with antipsychotic medication, both in terms of patient satisfaction and in the prevention of substance abuse.

Cannabis use and misuse prevalence among people with psychosis

BACKGROUND

Increasing attention has been given by researchers to cannabis use in individuals with psychosis. As psychoses are relatively low-prevalence disorders, research has been mostly been restricted to small-scale studies of treatment samples. The reported prevalence estimates obtained from these studies vary widely.

AIMS

To provide prevalence estimates based on larger samples and to examine sources of variability in prevalence estimates across studies.

METHOD

Data from 53 studies of treatment samples and 5 epidemiological studies were analysed.

RESULTS

Based on treatment sample data, prevalence estimates were calculated for current use (23.0%), current misuse (11.3%), 12-month use (29.2%), 12-month misuse (18.8%), lifetime use (42.1%) and lifetime misuse (22.5%). Epidemiological studies consistently reported higher cannabis use and misuse prevalence in people with psychosis.

CONCLUSIONS

The factor most consistently associated with increased odds of cannabis prevalence was specificity of diagnosis. Factors such as consumption patterns and study design merit further consideration.

The impact of substance use disorders on clinical outcome in 643 patients with first-episode psychosis

OBJECTIVE

Studies investigating the impact of comorbid substance use disorders (SUD) in psychosis have tended to focus on cross-sectional data, with few studies examining the effects of substance use course on clinical outcome. The main aim of the present study was to assess the impact of baseline SUD and course of SUD on remission of positive symptoms.

METHOD

The Early Psychosis Prevention and Intervention Centre admitted 786 first-episode psychosis (FEP) patients between 1998 and 2000. Data on SUD and clinical outcome were collected from patients' medical records (MR) of 643 patients who met inclusion criteria.

RESULTS

Lifetime prevalence of SUD was 74%, with 62% having a SUD at baseline. This reduced to 36% in those patients who completed 18 months of treatment at the EPPIC program. A Cox regression analysis indicated that a decrease or cessation of substance use significantly increased the probability of remission, whilst persistent SUD substantially reduced the likelihood. In addition, patients who reduced use appeared to have better outcomes at 18 months than those patients who had never used substances. Baseline SUD was not found to have any significant influence on symptom remission.

CONCLUSION

Patients presenting with FEP have high rates of SUD. Effective management of psychosis within a specialized service is associated with reductions in SUD over the course of treatment, although persistent substance use is associated with non-compliance, treatment drop-out and poor remission rates. As such, young people with FEP and comorbid substance use should be offered integrated treatment that addresses both disorders.

Comparisons between psychosis samples with different patterns of substance use recruited for clinical and epidemiological studies

Despite high rates of comorbid substance use disorders and smoking among people with psychotic disorders, previous studies have not examined differences in socio-demographic, clinical or disability characteristics between psychosis sub-groups with different patterns of substance use. This study compared the characteristics of five groups of people with psychosis and varying patterns of substance use (n=1152), including groups entering treatment studies for substance use or smoking, epidemiological samples of substance users and smokers, and people without such problems. Data were drawn from several recent Australian studies using comparable structured interviews and scales. There were moderate group differences in illness and symptom profiles, with substance users tending to have higher depression and reality distortion scores. Unexpectedly, personal disability was considerably lower among those seeking treatment for their substance use compared with the epidemiological groups, raising concerns about the appropriateness of traditional recruitment approaches in treatment studies and highlighting the need for more assertive treatment engagement and referral strategies in routine clinical settings. As a consequence of uncertainty about links between substance use and everyday functioning, it is suggested that health messages to young people may need to strike a better balance between the potential harms and benefits associated with substance use in pursuing broader harm minimization goals.